ACA & Ryan White: 6 Ways to Prepare - Providers

July 2014

TARGET Center

1. Become Involved in Marketplace Planning

See what ACA changes are under way in your state. See what's going on in your state around Marketplaces in terms of Medicaid expansion as well as individual and small-group coverage options. Seek out planning/advisory activities in your state around ACA and Marketplaces. Look especially to Ryan White planning groups that are involved in ACA implementation (eg, planning councils, state planning groups, collaborative activities with Medicaid).

Notably, Ryan White planning groups--and individual grantees--are reviewing their service priorities, allocations, contracts, and budgets as they consider changes in utilization of Ryan White resources in relation to new ACA insurance coverage options and other ACA activities. See guidance from HRSA's HIV/AIDS Bureau.

2. Expand Payer Options

Many Ryan White clients will be securing new coverage via Marketplaces. Coverage might come under expanded Medicaid or new individual health insurance coverage. Make sure your agency can continue to serve your clients, and be reimbursed for services, by lining up connections to payers. One option is to secure status as an approved Medicaid provider (work with your state's Medicaid office). Alternatively, become a provider under a Medicaid Managed Care Organization (MMCO), which is how most states are serving their Medicaid populations.

Another option is to establish new connections with health provider networks that have arrangements with health insurance companies that are offering individual and small-group coverage. A fourth option is to work directly with health insurance plans to become participating providers. Finally, designation under new care delivery models (eg, a Primary Care Medical Home or a Federally Qualified Health Center [FQHC] or Look-Alike FQHC through the HRSA Health Center program, described below) offers enhanced reimbursement options.

Regardless of the approach, understand the implications of being designated as a primary care provider versus a specialty care provider (i.e., an entity would need to be designated as a primary care provider in order to refer out to specialty care), and know what quality-of-care standards your agency must meet.

3. Maximize Reimbursement and Explore Restructuring Options

At a minimum, Ryan White agencies should review and, as necessary, enhance their third-party billing systems to make sure they are maximizing reimbursement by Medicaid and health plans. Agencies with limited services and reimbursement options may want to assess options for reorganization (eg, new partnerships or even mergers).

4. Explore Care Delivery Innovations

See how ACA is changing health care delivery. Consider new options for delivery of services, which may be eligible for added reimbursement. Under Medicaid, where many Ryan White clients will become newly eligible, most states deliver care to eligible individuals via Medicaid managed care.

ACA allows states the option to create Health Homes to provide coordinated care for persons with chronic conditions. Medicaid Health Homes also offer enhanced reimbursement rates. Other delivery and reimbursement options include securing status as a Primary Care Medical Home and exploring status under the HRSA Health Center program (as an FQHC or FQHC Look Alike).

5. Adjust Eligibility/Benefits Systems

ACA has established online systems to facilitate eligibility and enrollment for various coverage options (ie, Medicaid; individual, including tax credits/subsidies; small group). This "no wrong door" approach is for all state Marketplaces (state run, state partnership, and federally facilitated).

Adjust your agency's screening and eligibility systems in relation to HRSA/HAB policy guidances and this new streamlined environment. In addition, line up staff personnel (inside your agency or with an outside partner) who will help clients with benefits counseling, eligibility determinations, and tax credits/subsidies.

6. Engage in Outreach and Enrollment

Access enrollment resources, including tools tailored for individuals living with HIV/AIDS. See HRSA/HAB policy guidances on outreach, benefits counseling, and enrollment as well as premium and cost-sharing assistance for Ryan White clients receiving private health insurance and Medicaid.